Always treat on the bright side

NEW evidence that optimism can improve patient outcomes has sparked debate about whether doctors should withhold bad news from patients.

Research in Archives of Internal Medicine found that heart disease patients with higher expectations about their future lifestyle and prognosis had better functioning and survival over a 15-year follow-up. (1)

In a related editorial, Dr Robert Gramling and Dr Ronald Epstein, of the University of Rochester in New York, said the research adds to a “compelling body of evidence” showing that optimism for future heart health is associated with cardiovascular benefits. (2)

They suggest that this growing evidence could lead physicians to actively promote optimism, or even conceal negative information from patients.

“We might even consider ourselves ethically justified in withholding or obfuscating poor prognoses from patients,” they write.

However, Professor Martin Tattersall, professor of medicine at the University of Sydney, said there were other ways to sustain hope without lying or avoiding the discussion.

“There are hope-giving ways of talking about prognosis, and one of the least hope-giving ways is not to talk about it,” said Professor Tattersall, who has written extensively on communicating prognoses with patients. (3,4)

Carol Bennett, CEO of the Consumers Health Forum of Australia, said that withholding information from patients was “highly unethical” and disrespectful.

“How can you foster a relationship based on good communication and collaboration when one party is playing god and deciding what information a consumer should have?”

Ms Bennett agreed that optimism could be useful, but she said that withholding information removed the patient’s ability to take control to improve their health care.

Professor Tattersall recommended that to promote hope, clinicians could describe the best-case, worst-case and typical survival scenarios to patients, rather than focussing on the median survival time.

“Sustain the uncertainty … uncertainty is, in fact, hope-giving, but providing patients with just one number is the exact opposite,” he said.

He agreed with the editorial that optimism and realism can coexist, such that patients may hope for a miracle while acknowledging it might not happen.

The editorial writers used Captain Kirk and Commander Spock from Star Trek to illustrate the point that people often use optimism in the “face of less-than-optimistic evidence”.

“Is it the hyperrational, unemotional Spock whom we emulate? ‘Captain, the statistical likelihood that our plan will succeed is less than 4.3 percent.’ Or are we drawn to the ever-optimistic (and usually correct) Captain Kirk? ‘Spock, it will work.’ Well, when it comes to our hearts, we generally aspire to Captain Kirk,” the editorial said.

Although hope has been linked to improved outcomes, it also had a dark side. The editorial cautioned that unbridled optimism may leave patients devastated when reality set in, and could encourage patients to take on “burdensome treatments”.

Professor Tattersall agreed that extreme optimism could be harmful.

“What’s been shown in oncology is that if you think your prognosis is much better than it actually is, you don’t live longer but actually have a worse death, with more treatments and ICU admissions,” he said.

- Sophie McNamara

1. Arch Intern Med 2011; 171: 929-935

2. Arch Intern Med 2011; 171: 935-936

3. MJA 2007; 186: S77-108

4. JCO 2010; 28: 2802-2804

Posted 30 May 2011

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